- Medicaid programs across the country are working to address the non-medical drivers of health (DOH) and improve outcomes for their members; however, coordination of medical and non-medical services can be challenging.
- Community resource and referral platforms can support this type of coordination by supporting screening, providing a directory of non-medical services, and facilitating the referral process.
- Regional projects in Texas that aim to develop Community Information Exchanges (CIE) or CIE-like structures are incorporating community resource and referral platforms to share data across multiple platforms. These projects are in their early stages but show promise to improve care coordination and data usability.
- This brief shares experiences from Medicaid stakeholders in Texas on using community resource and referral platforms to identify and address non-medical DOH. While geared to a Texas audience, lessons herein can inform activities in other states to better address non-medical needs of Medicaid populations.
As Medicaid programs across the country become more aware of the major role non-medical drivers of health (DOH) play in health outcomes, they are increasingly searching for tools to help identify and address these needs. One such tool is a community resource and referral platform, which is designed to help coordinate screening for member needs, identify community resources, and facilitate referrals to community-based organizations (CBOs) and services to address these non-medical drivers.
Community resource and referral platforms have two main functions: (1) provide a directory of CBOs that deliver services to address non-medical DOH; and (2) help organizations make and manage referrals to CBOs for relevant services. Many platforms also offer additional functions, including integrating screening tools, providing a care management or care coordination platform, and supplying data analytics to help organizations track needs, utilization, and outcomes across their population. There are a variety of options for organizations looking to partner with a community resource and referral platform; a detailed overview of these platforms can be found in SIREN’s report Community Resource Referral Platforms: A Guide for Health Care Organizations. Texas’ Health and Human Services Commission (HHSC), Medicaid managed care organizations (MCOs), and Medicaid health care providers have all shown growing interest in addressing non-medical DOH. For instance, Texas stakeholders have been involved in developing directed payments that include a reporting measure for food insecurity screening, exploring the use of in lieu of services to address non-medical DOH, and participating in the Texas Medicaid MCO Social Determinants of Health Learning Collaborative. HHSC has also signaled interest in working towards better coordination of medical and non-medical service delivery in their Non-Medical Drivers of Health Action Plan, including through community resource and referral platforms. As this work progresses, it will be important to understand how key stakeholders — health-focused state agencies, MCOs, and providers (hereinafter referred to collectively as health care organizations [HCOs]) — are working with community resource and referral platforms to facilitate their work to address non-medical DOH. This brief explores the landscape of community resource and referral platforms in Texas Medicaid, outlines how stakeholders selected these platforms, and provides an overview of regional efforts to better coordinate and integrate use of these platforms.
To develop this brief, the Center for Health Care Strategies interviewed 11 Medicaid stakeholders in Texas, including Medicaid MCOs, HHSC staff overseeing the 211 system, provider organizations, and community resource and referral platform staff. The goal of these interviews was to better understand how member needs are being addressed, how community resource and referral platforms are being used to support identified needs, and how cross-sector partnerships are forming in this context. For a full list of interviewees, see Acknowledgements at the end of this brief.
Texas stakeholders reported using a variety of community resource and referral platforms. Following is a description of the main platforms currently in use in Texas. Note, this is only a snapshot of platforms currently in use in Texas, not a comprehensive list.
211 Texas Information and Referral Network (TIRN) is a state-run resource hotline. It is designed to be accessed by residents of Texas (who can search for services for themselves) or HCOs, who can call 211 TIRN or use its online chat platform to receive assistance identifying a local CBO to help meet their needs.
211 TIRN contracts with 25 Area Information Centers throughout the state, which work to keep the resource directory up-to-date and help manage referrals for individuals in their service area. 211 TIRN also partners with other state agencies to identify relevant services for their constituents and provides public data on non-medical needs across the state. Interviewees often felt that the 211 TIRN platform tends to have the most comprehensive and up-to-date resource directory compared to other platforms.
However, some interviewees in Texas reported that specific person-level data can be difficult for non-state partners to access due to the legal requirements governing data sharing. As a result, organizations reported that they need to create multiple data sharing relationships with 211 and other non-state partners, leading to duplicative workflows. Identifying ways to better integrate 211 into workflows established by Medicaid stakeholders and their partners could help prevent duplicative data sharing.
Findhelp, formerly known as Aunt Bertha, is a national resource and referral platform. Findhelp functions as a resource directory, referral management platform, a tool to track and analyze non-medical DOH data, and it can also provide needs screening. Similar to 211, findhelp allows individuals to search for resources on their own, or it can be used by HCOs, CBOs, or other partners. Findhelp has also developed the capacity to integrate with multiple other platforms, including commonly used medical records.
Findhelp is a common partner of many of the Medicaid MCOs in Texas; as of this writing, the platform is used by 11 Medicaid MCOs in the state. Blue Cross Blue Shield of Texas and Superior Health Plan both use Findhelp to understand local resources, refer members to services, and track needs among their members. Findhelp also provides expanded services in specific partnerships. For example, findhelp partners with Superior Health Plan to manage provision of car seats and diapers to new parents as a value-added benefit. Findhelp is also used by other customers in Texas, including 11 hospital systems, eight health centers, city and county governments, and United Ways and other large nonprofits.
Unite Us serves as a resource directory and referral management platform operating in 44 states across the country. Unite Us can be equipped with additional features based on the user’s needs, including prediction and measurement of individual- and community-level needs, data analysis, and payment management. North Carolina adopted Unite Us as the statewide community resource and referral platform in support of the Medicaid program’s Healthy Opportunities Pilots, the state’s 1115 waiver providing evidence-based, non-medical interventions related to housing, food, transportation, interpersonal safety, and toxic stress to high-need Medicaid enrollees.
In Texas, Unite Us has partnered with some major health systems and city governments, as well as smaller stakeholders. Unite Us recently partnered with the Texas Association of Community Health Centers (TACHC) to coordinate services to members at affiliated community health centers. Unite Us provides access to its platform to nonprofit CBOs and safety net organizations for free, and TACHC pays to receive additional data based on usage of the platform by its member health centers, including trends in non-medical DOH for their patients. Multiple TACHC member health centers are currently using Unite Us, and many more are in the process of engaging with Unite Us.
Many other platforms are being used throughout Texas to help serve Medicaid members. Some Medicaid MCOs, providers, Pathways Community HUBs, CBOs, and Accountable Communities of Health in Texas use other commercial platforms like Healthify/WellSky or have homegrown platforms. For example, the Parkland Center for Clinical Innovation used Pieces Connect, in the context of its broader Connected Communities of Care model.
Additional community resource and referral platforms that target specific populations also exist, such as Combined Arms, a Texas-based platform that focuses on serving veteran and military families by connecting them to clinical and community-based resources. Many of these platforms provide similar functionalities as the platforms discussed above.
During interviews, stakeholders in Texas shared the key considerations that led them to partner with certain community resource and referral platforms.
As previously discussed, community resource and referral platforms have many different functionalities. Interviewees reported that two functions of these functions were particularly important: (1) closed-loop referral management systems; and (2) interoperability with other medical or community resource and referral platforms.
A closed-loop referral system allows a user, for example an HCO (see Exhibit 1), to identify a member need, find the appropriate CBO to meet that need, send a referral to the CBO, and then see a response from the CBO when they have connected with the member.
Exhibit 1. Data Flows for HCOs
This process enables the HCO to ensure their members are actually accessing resources and track which CBOs are able to respond in a timely fashion to members’ needs. Interviewees noted that closed-loop referral systems were the most desired function in a community resource and referral platform. Correspondingly, most platforms offer a closed-loop referral system; however, some interviewees reported that these closed-loop systems did not always work smoothly. For instance, problems closing the loop may arise when CBOs or other stakeholders are not regularly using these platforms or have high volumes of referrals to track.
The second function that interviewees looked for in a community resource and referral platform was interoperability with other platforms, particularly electronic health records, but also other community resource and referral platforms and other state-owned data platforms (e.g., school system data). As Medicaid stakeholders across Texas – and the country – use a variety of different platforms to track medical care and non-medical service delivery, platforms that can communicate with each other and easily share data are in high demand. Unfortunately, universal interoperability is far from a reality. A lack of data standardization, difficulties with different privacy laws for medical versus non-medical data, and hesitancy to work with competing products means that most platforms offer only limited interoperability. Stakeholders have sometimes addressed interoperability by building their own platforms. For instance, multiple community health centers in Texas use homegrown platforms to manage needs screening, tracking, and referrals; these platforms integrate smoothly into their electronic health records, something that is not guaranteed by external platforms. Progress on interoperability is being made through efforts like the Gravity Project, which is working to develop federal standards for DOH data. New projects in Texas are identifying other opportunities to increase interoperability and are explored further in the section on Regional Interoperability Efforts.
Some interviewees reported developing a homegrown platform, rather than purchasing a platform from a vendor. For instance, the Grow Healthy Together Pathways HUB, part of The Health Collaborative in San Antonio, reported using a homegrown platform that grew out of a prior federally funded project to develop disease-specific service directories. This platform was given to The Health Collaborative, which modified it to fit their needs. Owning their own platform ensures they can easily make modifications, the platform will always be supported and will not go out of business, and saves them money – as contracting with community resource and referral platforms at the organizational level can be expensive. (Some platforms, including Unite Us, offer their main services to safety net health care provider organizations for free, but may charge for other features including advanced data analytics.)
In some cases, Medicaid stakeholders chose to work, or not work, with a certain platform based on what their partner organizations use to avoid any interoperability challenges. A Texas community health center is working in collaboration with a Medicaid MCO to onboard with Unite Us at the same time, a decision driven largely by TACHC’s choice to contract with Unite Us.
The willingness of organizations to follow the lead of others is influenced by the strength of their partnerships in addressing non-medical needs. MCOs interviewed for this brief generally reported that they are currently running their own screening and referral processes and have not yet developed close relationships with provider organizations to address non-medical member needs. As such, they are currently unlikely to consider which platforms are being used by contracted providers when making the decision about what platform to work with.
Across Texas, regional projects are gaining momentum to improve platform interoperability. Increased interoperability allows a wide variety of stakeholders to share individual-level data, gaining a complete understanding of the various needs of their patients or clients, and allowing them to better coordinate initiatives addressing a holistic set of needs across stakeholders, including, but not limited to, Medicaid stakeholders. These efforts often, but not always, take the shape of a Community Information Exchange (CIE), which combines data from multiple stakeholders and sectors, typically including medical and non-medical data, to support improved whole-person care.
The local efforts detailed below are located within Austin and Houston and the areas surrounding these cities. However, similar efforts are taking place across the state and in partnership with local governments, health plans, provider groups, and other organizations.
The Central Texas Model Community works in Austin and its surrounding communities to provide a cohesive experience for patients who seek clinical and community-based services by coordinating activities. The Model Community works with a variety of partners, including schools, health care providers, and CBOs to ensure medical and non-medical needs of community members are met. Many different organizations are part of the Model Community project. The United Way for Greater Austin is the backbone organization, working to implement the project. Community resource and referral platforms, including findhelp and Texas 211, are involved to help provide connections to services. Additional data-focused organizations – the Connxus Health Information Exchange and the Social and Health Information Platform (SHIP) out of Dell Medical School (explored in detail below) – support the project by providing access to health data, data aggregation, and data-sharing/interoperability capabilities. Given the nature of the Model Community project, it is likely to impact many Medicaid enrollees living in this region of Texas, and Medicaid stakeholders may benefit from learnings from this project.
ConnectATX is a platform run through the United Way for Greater Austin and was developed in partnership with Texas 211 and findhelp. ConnectATX is a community resource and referral platform developed to provide more personalized and intensive assistance to people with multiple, complex, and ongoing non-medical needs. For example, most users access the resource directories hosted by 211 and findhelp online, but people referred to ConnectATX can be directly connected to an employee of 211 who can help them navigate multiple referrals to CBOs, using the findhelp platform. ConnectATX navigators typically spend more time with clients and are able to build on ongoing relationship to support their higher needs. ConnectATX is one of the many platforms that provides data on non-medical needs and referrals to the Central Texas Model Community and acts as a public-facing entry point into the Model Community project.
Implementation of the Central Texas Model Community is in early stages. Partners are working to find the best ways to handle data governance, ensure data accuracy, formalize roles of the partners, and set evaluation metrics. As of this writing, there is no formal involvement by Texas HHSC or Medicaid MCOs.
The Health Equity Collective is a multi-sector collaborative focused on improving care coordination for whole-person services in the Greater Houston region. UTHealth Houston School of Public Health serves as the backbone organization for the Collective, and generates research and reports on Collective activities. For example, a 2020 report and community information exchange blueprint discussed technology organizations, tools, and data sets in the region, including the Greater Houston Healthconnect Health Information Exchange, Combined Arms, Open Referral, Patient Care Intervention Center, and Welnity.
The Health Equity Collective is supporting the development of a community information exchange/closed loop referral system in the Greater Houston region that leverages the Greater Houston Healthconnect Health Information Exchange and links health care and non-medical services. A demonstration project involving nine health care and social service agencies is currently underway.
SHIP is a project currently in development out of Dell Medical School. The goal of SHIP is to develop a data aggregator platform that can take in data from multiple medical and non-medical service platforms, aggregate and synthesize the data, and present data on customizable and digestible dashboards. These dashboards will be designed for use by HCOs, CBOs, and other service providers to track the needs and referrals of individual patients. Data could also be displayed at a population level. Additionally, the developers of SHIP are working on pilot projects that incorporate patient-facing software into a screening and closed-loop referral system, allowing the patient to contribute the self-reported data to the data aggregator and be a partner in identifying and managing referrals to services.
SHIP is in the early stages of implementation. It is currently being tested by multiple federally qualified health centers and clinical providers in Austin and is looking to expand to some neighboring counties in the near future. Additionally, Travis County Health Department and all health systems in the area recently partnered to select SHIP as their universally adopted platform, in integration with the Connxus Health Information Exchange; initial integration efforts are just beginning.
Interviewees also discussed projects outside of the Austin and Houston areas. For instance, in Waco, the local accountable health community brought together MCOs, a local health system, the police department, and a network of CBOs to create a referral network for high-risk members identified by the MCO. Key partners in this effort include Baylor Scott & White Health Plan, Prosper Waco, and the United Way of Central Texas. In Central Texas, Findhelp and the Connxus Health Information Exchange are exploring additional partnership opportunities to support initiatives from the clinical and hospital users of Connxus.
There are currently many community resource and referral platforms available in Texas that can help stakeholders understand, track, and manage interventions to address the non-medical needs faced by their members/patients. Additionally, multiple regional projects in Texas are working to improve the interoperability of these types of platforms. Stakeholders in the Austin and Houston area are partnering to develop CIE-like platforms that can aggregate data from multiple sources, share data broadly, and ultimately improve coordination of medical and non-medical care. While these projects are generally in the early stages and still have a lot to learn about data governance and interoperability, their wide uptake by a diverse set of stakeholders shows promise.
Stakeholders in Texas are excited about additional advances that will continue to support these types of projects. For instance, efforts to develop DOH data standards will lead to increased interoperability of platforms. Adoption of certain platforms by local governments can create greater coordination in specific regions. And innovative partnerships between HCOs, CBOs, and community resource and referral platforms can develop effective methods to meaningfully address non-medical DOH.